Long-Term Outcomes of Surgeon-Modified Fenestrated TEVAR at Zone 2 Landing

Surgeon-modified fenestrated stent grafts (SMFSGs) have emerged to overcome limitations related to manufacturing delays, high procedural costs, anatomical constraints, and limited availability of custom-made branched or fenestrated endografts. The aim of this study was to evaluate the safety, feasibility, and mid- to long-term follow-up outcomes of the SMFSG technique for zone 2 landing using the Lifetech Ankura™ thoracic endograft.

Between January 2020 and January 2026, 41 consecutive patients with thoracic aortic pathology requiring zone 2 landing and left subclavian artery (LSA) revascularization using SMFSG with the Lifetech Ankura thoracic endograft (Lifetech Scientific, Shenzhen, China) were included in the study. No reinforcement sutures were used during graft modification. The primary and secondary endpoints were overall mortality and aorta-related mortality (ARM), endoleak, patency of LSA, and reinterventions in the follow-up period.

The mean age of the patient cohort was 58.2 ± 11.2 (34-85) years. There was no open conversion to surgery, and technical success was 100% according to the study definition. Eight patients (19.5%) underwent selective primary balloon-expandable stent placement in the LSA to optimize branch patency. Nine patients (21.95%) underwent the procedure under emergency conditions. The mean intensive care unit period was 14.8 ± 7.1 hours (4-36 hours). The mean length of stay was 3.8 ± 1.4 days (3-6 days). The fenestration procedure took a mean period of 11.3 ± 3.2 minutes (8-18 minutes). The fluoroscopy period was 9.2 ± 4.3 minutes (4-22 minutes). The follow-up period was 51.9 ± 13.6 months (5-66 months). Primary and secondary LSA patency rates were 100% and 97.6% for the follow-up period. Two patients experienced type 1a endoleak, and both had thoracic endovascular aortic repair (TEVAR) and carotid-subclavian bypass at the 12th and 18th month. One patient died at the 28th month due to cardiac causes. There was no ARM.

In this retrospective single-center series, surgeon-modified fenestrated TEVAR using the Lifetech Ankura thoracic endograft was feasible and achieved high technical success with favorable LSA patency and encouraging follow-up outcomes. However, interpretation is limited by the small sample size, heterogeneous pathology, and limited number of late events. Larger comparative studies are needed to better define durability and pathology-specific performance.